Diabetes and ethnic minorities

Diet and Physical Activity Interventions for People from Minority Ethnic Backgrounds in the UK: A Scoping Review Exploring Barriers, Enablers and Cultural Adaptations

BACKGROUND

Type 2 diabetes (T2D) and cardiovascular disease (CVD) are a global pandemic, driven by obesity, poor diet and physical inactivity. In the UK, the prevalence of T2D and CVD is higher in minority ethnic groups. Lifestyle prevention interventions can be effective but uptake amongst minority ethnic groups in the UK is low and the extent of cultural adaptations to increase engagement unknown.

AIM

To explore barriers, enablers and culturally adapted lifestyle interventions in UK minority ethnic groups.

METHODS

Four electronic databases were searched from to January 2013-2023. Two independent reviewers carried out manuscript selection and data extraction. Barriers and enablers were mapped to the Capability + Opportunity + Motivation = Behaviour (COM-B) theoretical model. Intervention adaptations were linked to behaviour change strategies and reported within a Cultural Adaptation framework.

RESULTS

Twenty-three studies were included, reporting barriers/enablers, culturally adapted interventions or both. Barriers and enablers mostly mapped to social and physical opportunity, and reflective motivation. Common adaptation strategies considered behavioural influences related to culture, values, religious beliefs and/or traditions. Most impactful strategies were associated with using credible sources of information and reorganising social and environmental contexts.

DISCUSSION AND CONCLUSIONS

The current umbrella approach to preventative intervention delivery is unlikely to promote sustained participation in behaviour change amongst UK ethnic minorities. Engagement strategies for this population should consider key determinants such as social contexts, beliefs and cultural norms. Important research gaps include interventions investigating tailored interventions for Black populations, and the impact of negative social experiences (e.g., racism) on engagement.

Ethnicity and outcomes for patients with gastrointestinal disorders attending an emergency department serving a multi-ethnic population

BACKGROUND

Ethnic inequalities in acute health acute care are not well researched. We examined how attendee ethnicity influenced outcomes of emergency care in unselected patients presenting with a gastrointestinal (GI) disorder.

METHODS

A descriptive, retrospective cohort analysis of anonymised patient level data for University Hospitals of Leicester emergency department attendees, from 1 January 2018 to 31 December 2021, receiving a diagnosis of a GI disorder was performed. The primary exposure of interest was self-reported ethnicity, and the two outcomes studied were admission to hospital and whether patients underwent clinical investigations. Confounding variables including sex and age, deprivation index and illness acuity were adjusted for in the analysis. Chi-squared and Kruskal-Wallis tests were used to examine ethnic differences across outcome measures and covariates. Multivariable logistic regression was used to examine associations between ethnicity and outcome measures.

RESULTS

Of 34,337 individuals, median age 43 years, identified as attending the ED with a GI disorder, 68.6% were White. Minority ethnic patients were significantly younger than White patients. Multiple emergency department attendance rates were similar for all ethnicities (overall 18.3%). White patients had the highest median number of investigations (6, IQR 3-7), whereas those from mixed ethnic groups had the lowest (2, IQR 0-6). After adjustment for age, sex, year of attendance, index of multiple deprivation and illness acuity, all ethnic minority groups remained significantly less likely to be investigated for their presenting illness compared to White patients (Asian: aOR 0.80, 95% CI 0.74-0.87; Black: 0.67, 95% CI 0.58-0.79; mixed: 0.71, 95% CI 0.59-0.86; other: 0.79, 95% CI 0.67-0.93; p < 0.0001 for all). Similarly, after adjustment, minority ethnic attendees were also significantly less likely to be admitted to hospital (Asian: aOR 0.63, 95% CI 0.60-0.67; Black: 0.60, 95% CI 0.54-0.68; mixed: 0.60, 95% CI 0.51-0.71; other: 0.61, 95% CI 0.54-0.69; p < 0.0001 for all).

CONCLUSIONS

Significant differences in usage patterns and disparities in acute care outcomes for patients of different ethnicities with GI disorders were observed in this study. These differences persisted after adjustment both for confounders and for measures of deprivation and illness acuity and indicate that minority ethnic individuals are less likely to be investigated or admitted to hospital than White patients.

Development and Validation of Prediction Models for the 5-year Risk of Type 2 Diabetes in a Japanese Population: Japan Public Health Center-based Prospective (JPHC) Diabetes Study

BACKGROUND

This study aimed to develop models to predict the 5-year incidence of type 2 diabetes mellitus (T2DM) in a Japanese population and validate them externally in an independent Japanese population.

METHODS

Data from 10,986 participants (aged 46-75 years) in the development cohort of the Japan Public Health Center-based Prospective Diabetes Study and 11,345 participants (aged 46-75 years) in the validation cohort of the Japan Epidemiology Collaboration on Occupational Health Study were used to develop and validate the risk scores in logistic regression models.

RESULTS

We considered non-invasive (sex, body mass index, family history of diabetes mellitus, and diastolic blood pressure) and invasive (glycated hemoglobin [HbA1c] and fasting plasma glucose [FPG]) predictors to predict the 5-year probability of incident diabetes. The area under the receiver operating characteristic curve was 0.643 for the non-invasive risk model, 0.786 for the invasive risk model with HbA1c but not FPG, and 0.845 for the invasive risk model with HbA1c and FPG. The optimism for the performance of all models was small by internal validation. In the internal-external cross-validation, these models tended to show similar discriminative ability across different areas. The discriminative ability of each model was confirmed using external validation datasets. The invasive risk model with only HbA1c was well-calibrated in the validation cohort.

CONCLUSION

Our invasive risk models are expected to discriminate between high- and low-risk individuals with T2DM in a Japanese population.

Twenty years of participation of racialised groups in type 2 diabetes randomised clinical trials: a meta-epidemiological review

AIMS/HYPOTHESIS

Type 2 diabetes mellitus prevalence is increasing globally and the greatest burden is borne by racialised people. However, there are concerns that the enrolment of racialised people into RCTs is limited, resulting in a lack of ethnic and racial diversity. This may differ depending whether an RCT is government funded or industry funded. The aim of this study was to review the proportions of racialised and white participants included in large RCTs of type 2 diabetes pharmacotherapies relative to the disease burden of type 2 diabetes in these groups.

METHODS

The Ovid MEDLINE database was searched from 1 January 2000 to 31 December 2020. English language reports of RCTs of type 2 diabetes pharmacotherapies published in select medical journals were included. Studies were included in this review if they had a sample size of at least 100 participants and all participants were adults with type 2 diabetes. Industry-funded trials must have recruited participants from at least two countries. Government-funded trials were not held to the same standard because they are typically conducted in a single country. Data including the numbers and proportions of participants by ethnicity and race were extracted from trial reports. The participation-to-prevalence ratio (PPR) was calculated for each trial by dividing the percentage of white and racialised participants in each trial by the percentage of white and racialised participants with type 2 diabetes, respectively, for the regions of recruitment. A random-effects meta-analysis was used to generate the pooled PPRs and 95% CIs across study types. A PPR <0.80 indicates under-representation and a PPR >1.20 indicates over-representation. Risk of bias assessments were not conducted for this study as the objective was to examine recruitment of racialised and white participants rather than evaluate the trustworthiness of clinical trial outcomes.

RESULTS

A total of 83 trials were included, involving 283,122 participants, of which 15 were government-funded and 68 were industry-funded trials. In government-funded trials, the PPR for white participants was 1.11 (95% CI 0.99, 1.24) and the PPR for racialised participants was 0.72 (95% CI 0.60, 0.86). In industry-funded trials, the PPR for white participants was 1.95 (95% CI 1.74, 2.18) and the PPR for racialised participants was 0.36 (95% CI 0.32, 0.42). The limitations of this study include the reliance on investigator-reported ethnicity and race to classify participants as 'white' or 'racialised', the use of estimates for type 2 diabetes prevalence and demographic data, and the high levels of heterogeneity of pooled estimates. However, despite these limitations, the results were consistent with respect to direction.

CONCLUSIONS/INTERPRETATION

Racialised participants are under-represented in government- and industry-funded type 2 diabetes trials. Strategies to improve recruitment and enrolment of racialised participants into RCTs should be developed.

REGISTRATION

Open Science Framework registration no. f59mk ( https://osf.io/f59mk ) FUNDING: The authors received no financial support for this research or authorship of the article.

Assessing the prediction of type 2 diabetes risk using polygenic and clinical risk scores in South Asian study populations

Background

Genome-wide polygenic risk scores (PRS) have shown high specificity and sensitivity in predicting type 2 diabetes (T2D) risk in Europeans. However, the PRS-driven information and its clinical significance in non-Europeans are underrepresented. We examined the predictive efficacy and transferability of PRS models using variant information derived from genome-wide studies of Asian Indians (AIs) (PRSAI) and Europeans (PRSEU) using 13,974 AI individuals.

Methods

Weighted PRS models were constructed and analyzed on 4602 individuals from the Asian Indian Diabetes Heart Study/Sikh Diabetes Study (AIDHS/SDS) as discovery/training and test/validation datasets. The results were further replicated in 9372 South Asian individuals from UK Biobank (UKBB). We also assessed the performance of each PRS model by combining data of the clinical risk score (CRS).

Results

Both genetic models (PRSAI and PRSEU) successfully predicted the T2D risk. However, the PRSAI revealed 13.2% odds ratio (OR) 1.80 [95% confidence interval (CI) 1.63-1.97; p = 1.6 × 10-152] and 12.2% OR 1.38 (95% CI 1.30-1.46; p = 7.1 × 10-237) superior performance in AIDHS/SDS and UKBB validation sets, respectively. Comparing individuals of extreme PRS (ninth decile) with the average PRS (fifth decile), PRSAI showed about two-fold OR 20.73 (95% CI 10.27-41.83; p = 2.7 × 10-17) and 1.4-fold OR 3.19 (95% CI 2.51-4.06; p = 4.8 × 10-21) higher predictability to identify subgroups with higher genetic risk than the PRSEU. Combining PRS and CRS improved the area under the curve from 0.74 to 0.79 in PRSAI and 0.72 to 0.75 in PRSEU.

Conclusion

Our data suggest the need for extending genetic and clinical studies in varied ethnic groups to exploit the full clinical potential of PRS as a risk prediction tool in diverse study populations.

Metformin in the prevention of type 2 diabetes after gestational diabetes in postnatal women (OMAhA): a UK multicentre randomised, placebo-controlled, double-blind feasibility trial with nested qualitative study

OBJECTIVE

To determine the feasibility of a definitive trial of metformin to prevent type 2 diabetes in the postnatal period in women with gestational diabetes.

DESIGN

A multicentre, placebo-controlled, double-blind randomised feasibility trial with qualitative evaluation.

SETTING

Three inner-city UK National Health Service hospitals in London.

PARTICIPANTS

Pregnant women with gestational diabetes treated with medication.

INTERVENTIONS

2 g of metformin (intervention) or placebo (control) from delivery until 1 year postnatally.

PRIMARY OUTCOME MEASURES

Rates of recruitment, randomisation, follow-up, attrition and adherence to the intervention.

SECONDARY OUTCOME MEASURES

Preliminary estimates of glycaemic effects, qualitative exploration, acceptability of the intervention and costs.

RESULTS

Out of 302 eligible women, 57.9% (175/302) were recruited. We randomised 82.3% (144/175) of those recruited, with 71 women in the metformin group and 73 women in the placebo group. Of the participants remaining in the study and providing any adherence information, 54.1% (59/109) took at least 75% of the target intervention dose; the overall mean adherence was 64% (SD 33.6). Study procedures were found to be acceptable to women and healthcare professionals. An increased perceived risk of developing type 2 diabetes, or a positive experience of taking metformin during pregnancy, encouraged participation and adherence to the intervention. Barriers to adherence included disruption to the medication schedule caused by the washout periods ahead of each study visit or having insufficient daily reminders.

CONCLUSIONS

It is feasible to run a full-scale definitive trial on the effectiveness of metformin to prevent type 2 diabetes in women with gestational diabetes, during the early postnatal period. Adherence and engagement with the study could be improved with more regular reminders and potentially the addition of ongoing educational or peer support to reinforce messages around type 2 diabetes prevention.

TRIAL REGISTRATION NUMBER

ISRCTN20930880.

Transmission of Variant Creutzfeldt-Jakob Disease Through Blood Transfusion and Plasma-Derived Products: A Narrative Review of Observed and Modeled Risks

Secondary transmission of variant Creutzfeldt-Jakob disease (vCJD) can occur through blood transfusion or receipt of plasma-derived products. However, published reviews on this topic are outdated, focused on a single country or product type, or did not comprehensively review modeling studies on the risk of transfusion-transmission. We reviewed existing data on observed and modeled risks of transfusion-transmission of vCJD. To date, five patients are suspected to have acquired clinical vCJD or a vCJD infection after receiving a blood or plasma-derived product from a donor who later developed clinical vCJD. All of these cases received a nonleukodepleted blood-derived product in the United Kingdom between 1994 and 1999. Thus, all transfusion-associated cases occurred before the adoption of universal leukodepletion in 1999, which supports the preferential tropism of vCJD for leukocytes. In descriptive cohort studies, no cases of clinical vCJD were observed over ∼13 years of follow-up. In modeling studies, the risk of collecting a contaminated donation was generally <23 per million donations, that of infection was generally <10 per million transfusions or doses, and that of clinical vCJD was generally <2 per million transfusions or doses. These low risk estimates and the two-decade long absence of new cases of transfusion-associated vCJD suggest vCJD poses minimal risks to the safety of the blood supply. Furthermore, despite concerns of a second wave driven by individuals harboring a non-MM genotype at codon 129 of PRNP, there has been only 1 autopsy-confirmed case of clinical vCJD in an MV individual in 2016. The current trend to reassess or (in some countries) fully withdraw the blood donation criteria related to vCJD therefore seems justified, safe, and may significantly expand the donor base.

Genetic and Functional Effects of Adiponectin in Type 2 Diabetes Mellitus Development

Diabetes mellitus (DM) is a common chronic metabolic disease, and the C57BLKsJ-db/db mice are good animal models for type 2 diabetes mellitus (T2DM). In this study, Western blotting and immunohistochemistry (IHC) were employed to examine the protein expression of adiponectin in the liver tissues of T2DM mice with different disease courses (4, 16, and 32 weeks). Adiponectin expression reduced in the liver tissues of T2DM mice in different disease courses. The genotypic and allelic frequencies of the adiponectin gene rs1063538 and rs2241766 single nucleotide polymorphisms (SNPs) in a Taiwanese population (570 T2DM patients and 1700 controls) were investigated. Based on the genetic distribution of the rs2241766 locus, the distribution frequency of the T allele in the T2DM group (72.8%) was higher than in the control group (68.8%). Individuals carrying the G allele had a 0.82-fold greater risk of developing T2DM than individuals carrying the T allele. Differences were evident in the genotypic and allelic distributions (p < 0.05). Enzyme-linked immunosorbent assay (ELISA) was used to measure changes in serum adiponectin protein concentrations in the healthy population and in patients with T2DM. Serum adiponectin concentration in patients with T2DM was lower than in the control group. In summary, adiponectin was determined to be a T2DM susceptibility gene and may be involved in T2DM progression.

A discourse analysis of General Medical Council (GMC) guidelines for the inclusion of cultural diversity issues in medical education and practice

BACKGROUND

Several studies have highlighted the insufficient inclusion of cultural diversity in medical schools' curricula and the extent of health inequalities highlighted by the COVID-19 pandemic. This study aimed to critically review a range of GMC publications to identify the inclusion of cultural diversity topics in their guidelines, as according to recent studies, doctors are inadequately prepared to serve a diverse population.

METHODS

Twenty-four relevant GMC publications were analysed. An inductive thematic analysis was conducted to review the content of the guidelines; and discourse analysis was used to critically understand the linguistics used whilst also considering the cultural and social context.

RESULTS

The GMC publications primarily focused on discouraging discrimination and promoting equality. Themes around diversity in medical practice were less commonly covered. There was considerable internal inconsistency across the guidelines. Guidelines aimed at medical schools and medical students were more likely to consider cultural diversity issues compared to those intended for doctors.

CONCLUSIONS

Cultural diversity teaching can only be as effective as the policy that drives it. Despite the inclusion of cultural diversity issues in GMC guidelines, this study suggests considerable ambiguity in how these issues are represented and understood. The guidelines require careful revision and should be written to reduce the likelihood of variable interpretation, thereby promoting better cultural diversity inclusion in medical schools' curricula, and consequently better patient care.

Ethnic disparities in mortality among overweight or obese adults with newly diagnosed type 2 diabetes: a population-based cohort study

PURPOSE

Ethnic variation in risk of type 2 diabetes is well established, but its impact on mortality is less well understood. This study investigated the risk of all-cause and cardiovascular mortality associated with newly diagnosed type 2 diabetes in White, Asian and Black adults who were overweight or obese.

METHODS

This population-based cohort study used primary care records from the UK Clinical Practice Research Datalink, linked with secondary care and death registry records. A total of 193,528 obese or overweight adults (BMI of 25 or greater), with ethnicity records and no pre-existing type 2 diabetes were identified between 01 January 1995 and 20 April 2018. Multivariable Cox proportional hazards regression estimated hazards ratios (HR) for incident type 2 diabetes in different ethnic groups. Adjusted hazards ratios for all-cause and cardiovascular mortality were determined in individuals with newly diagnosed type 2 diabetes.

RESULTS

During follow-up (median 9.8 years), the overall incidence rate of type 2 diabetes (per 1,000 person-years) was 20.10 (95% CI 19.90-20.30). Compared to Whites, type 2 diabetes risk was 2.2-fold higher in Asians (HR 2.19 (2.07-2.32)) and 30% higher in Blacks (HR 1.34 (1.23-1.46)). In individuals with newly diagnosed type 2 diabetes, the rates (per 1,000 person-years) of all-cause mortality and cardiovascular mortality were 24.34 (23.73-24.92) and 4.78 (4.51-5.06), respectively. Adjusted hazards ratios for mortality were significantly lower in Asians (HR 0.70 (0.55-0.90)) and Blacks (HR 0.71 (0.51-0.98)) compared to Whites, and these differences in mortality risk were not explained by differences in severity of hyperglycaemia.

CONCLUSIONS/INTERPRETATION

Type 2 diabetes risk in overweight and obese adults is greater in Asian and Black compared to White ethnic populations, but mortality is significantly higher in the latter. Greater attention to optimising screening, disease and risk management appropriate to all communities with type 2 diabetes is needed.

Purine metabolites can indicate diabetes progression

AIM

To find the association between purine metabolites and diabetic complications in rats.

MATERIALS AND METHODS

Alloxan was administered to induce diabetes in rats. After 30 days, the levels of uric acid, inosine, xanthine, hypoxanthine and AMP were assessed in both plasma and liver tissues using HPLC technique.

RESULTS

A significant increase in xanthine, hypoxanthine, AMP levels (p < .001 and t-value 2.78) and inosine in plasma and liver tissues (p < .05 and t-value 2.11) with a concomitant increase in uric acid levels (p < .001 and t-value 2.80) was observed in diabetic group.

CONCLUSION

Purine metabolites like uric acid and other intermediate products of purine metabolism are increased in diabetes. These results can be used in addition or separately in evaluating the progression of diabetes.

Ramadan is not associated with increased infection risk in Pakistani and Bangladeshi populations: Findings from controlled interrupted time series analysis of UK primary care data

Background

The effect of fasting on immunity is unclear. Prolonged fasting is thought to increase the risk of infection due to dehydration. This study describes antibiotic prescribing patterns before, during, and after Ramadan in a primary care setting within the Pakistani and Bangladeshi populations in the UK, most of whom are Muslims, compared to those who do not observe Ramadan.

Method

Retrospective controlled interrupted time series analysis of electronic health record data from primary care practices. The study consists of two groups: Pakistanis/Bangladeshis and white populations. For each group, we constructed a series of aggregated, daily prescription data from 2007 to 2017 for the 30 days preceding, during, and after Ramadan, respectively.

Findings

Controlling for the rate in the white population, there was no evidence of increased antibiotic prescription in the Pakistani/Bangladeshi population during Ramadan, as compared to before Ramadan (IRR: 0.994; 95% CI: 0.988–1.001, p = 0.082) or after Ramadan (IRR: 1.006; 95% CI: 0.999–1.013, p = 0.082).

Interpretation

In this large, population-based study, we did not find any evidence to suggest that fasting was associated with an increased susceptibility to infection.

Adolescent Immigration and Type-2 Diabetes

PURPOSE OF REVIEW

Type-2 diabetes (T2D) in children and adolescents has become an increasingly important public health concern, currently accounting for nearly half of all diabetes cases in this age group in some countries. With immigration growing worldwide, immigrants as a subpopulation warrant special attention. Although the association of immigration and T2D has been explored in older persons, few studies have examined it in adolescent immigrants.

RECENT FINDINGS

Of 64 studies, only 8 were relevant and elaborated on in this review. Our findings show that adolescent immigrants to Western countries seem to benefit an overall favorable metabolic profile that is associated with lower odds to dysmetabolism. However, this protective effect wanes over time with longer years of residency and plateaus at approximately a decade from arrival. As immigration becomes a global phenomenon, pediatric T2D in these special populations has major public health and socioeconomic implications. Improving immigrants' access to healthcare, healthcare education and utilization, and specific cultural programs for prevention and treatment of T2D are important to ensure the accessibility of preventive medical services to young immigrants. Further research should be considered to help identify at-risk youth.

Characterizing screening strategies for type 2 diabetes in high-risk ethnic communities: a scoping review protocol

OBJECTIVE

This review aims to identify the characteristics of screening strategies for type 2 diabetes to determine the most pragmatic approach to improve relevance to high-risk community groups from ethnically diverse backgrounds.

INTRODUCTION

Type 2 diabetes is increasingly contributing to the global burden of disease and is more common in some community groups. Although screening underpins the success of primary prevention programs for type 2 diabetes, screening of high-risk community groups from ethnically diverse backgrounds require different screening protocols and can be challenging. These strategies have never been systematically scoped.

INCLUSION CRITERIA

This scoping review will consider screening strategies for type 2 diabetes that target high-risk ethnic community groups. Studies with adults older than 18 years will be considered for inclusion. Screening strategies may include, but are not limited to, risk-assessment questionnaires, blood tests, or both, using an opportunistic approach involving general practices or a targeted approach toward high-risk community groups from ethnically diverse backgrounds. Experimental and observational quantitative studies and mixed methods studies will be included.

METHODS

MEDLINE, CINAHL, PsycINFO, Informit, ProQuest, Web of Science, and Scopus will be searched. Studies will be screened for inclusion by two independent reviewers, and data will be extracted using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Results will be summarized in tables accompanied by narrative text.

Prevalence of diabetes mellitus and hypertension amongst the HIV-positive population at a district hospital in eThekwini, South Africa

Background

Life expectancies of HIV-positive patients have been increasing with the rapid implementation of antiretroviral therapy (ART). This has led to an increase in comorbidities such as diabetes mellitus (DM) and hypertension (HT) amongst the HIV population. The burden of the non-communicable diseases (NCDs) such as DM and HT need to be quantified in order to ensure that patients receive optimal integrated care as patients often access care at different clinics compromising holistic care.

Aim

The aim of the study was to determine the prevalence of DM and HT amongst the HIV-positive population.

Setting

The study was conducted at Wentworth Hospital, a district facility in South Durban, KwaZulu-Natal.

Methods

This cross-sectional study was undertaken to determine the prevalence of two NCDs, namely DM and HT in HIV-positive patients attending the ART clinic at a district hospital in the eThekwini district. We compared the socio-demographic and clinical profiles of those with and without comorbidities. A sample of 301 HIV-positive patients were administered a structured questionnaire.

Results

Of the 301 patients, 230 (76.41%) had HIV only (95% confidence interval [CI]: 71.25–80.89) and 71 (23.59%) had HIV and at least one comorbidity, namely DM and/or HT (95% CI: 19.11-28.75). Hypertension was the most prevalent comorbidity. This study revealed that there was no association between the duration of ART and comorbidities. Older age and body mass index (BMI) were associated with comorbidities, whilst gender and ethnicity were not associated.

Conclusion

Non-communicable diseases such as DM and HT do pose a burden for HIV-positive patients attending the ARV clinic at this district facility. This study highlights the definite need to plan for the increased burden of NCDs as HIV-positive patients live longer and gain weight.

Association Between Race and COVID-19 Outcomes Among 2.6 Million Children in England

IMPORTANCE

Although children mainly experience mild COVID-19 disease, hospitalization rates are increasing, with limited understanding of underlying factors. There is an established association between race and severe COVID-19 outcomes in adults in England; however, whether a similar association exists in children is unclear.

OBJECTIVE

To investigate the association between race and childhood COVID-19 testing and hospital outcomes.

DESIGN, SETTING, PARTICIPANTS

In this cohort study, children (0-18 years of age) from participating family practices in England were identified in the QResearch database between January 24 and November 30, 2020. The QResearch database has individually linked patients with national SARS-CoV-2 testing, hospital admission, and mortality data.

EXPOSURES

The main characteristic of interest is self-reported race. Other exposures were age, sex, deprivation level, geographic region, household size, and comorbidities (asthma; diabetes; and cardiac, neurologic, and hematologic conditions).

MAIN OUTCOMES AND MEASURES

The primary outcome was hospital admission with confirmed COVID-19. Secondary outcomes were SARS-CoV-2-positive test result and any hospital attendance with confirmed COVID-19 and intensive care admission.

RESULTS

Of 2 576 353 children (mean [SD] age, 9.23 [5.24] years; 48.8% female), 410 726 (15.9%) were tested for SARS-CoV-2 and 26 322 (6.4%) tested positive. A total of 1853 children (0.07%) with confirmed COVID-19 attended hospital, 343 (0.01%) were admitted to the hospital, and 73 (0.002%) required intensive care. Testing varied across race. White children had the highest proportion of SARS-CoV-2 tests (223 701/1 311 041 [17.1%]), whereas Asian children (33 213/243 545 [13.6%]), Black children (7727/93 620 [8.3%]), and children of mixed or other races (18 971/147 529 [12.9%]) had lower proportions. Compared with White children, Asian children were more likely to have COVID-19 hospital admissions (adjusted odds ratio [OR], 1.62; 95% CI, 1.12-2.36), whereas Black children (adjusted OR, 1.44; 95% CI, 0.90-2.31) and children of mixed or other races (adjusted OR, 1.40; 95% CI, 0.93-2.10) had comparable hospital admissions. Asian children were more likely to be admitted to intensive care (adjusted OR, 2.11; 95% CI, 1.07-4.14), and Black children (adjusted OR, 2.31; 95% CI, 1.08-4.94) and children of mixed or other races (adjusted OR, 2.14; 95% CI, 1.25-3.65) had longer hospital admissions (≥36 hours).

CONCLUSIONS AND RELEVANCE

In this large population-based study exploring the association between race and childhood COVID-19 testing and hospital outcomes, several race-specific disparities were observed in severe COVID-19 outcomes. However, ascertainment bias and residual confounding in this cohort study should be considered before drawing any further conclusions. Overall, findings of this study have important public health implications internationally.

Telemedicine for Disparity Patients With Diabetes: The Feasibility of Utilizing Telehealth in the Management of Uncontrolled Type 2 Diabetes in Black and Hispanic Disparity Patients; A Pilot Study

BACKGROUND

Non-Hispanic Black (NHB) and Hispanic/Latinx (H/L) patients bear a disproportionate burden of type 2 diabetes and associated complications. Regular visits to a primary care doctor or diabetes specialist are warranted to maintain glycemic control, but for a myriad of reasons disparity populations may have difficulties receiving diabetes care. We seek to determine the feasibility of telehealth added to care as usual and secondarily to improve health outcomes (hemoglobin A1c [HbA1c]) in NHB and H/L with uncontrolled type 2 diabetes managed with two or three noninsulin agents.

METHODS

Twenty-nine patients were randomized to monthly phone calls or weekly to biweekly telehealth visits. Feasibility outcomes were summarized descriptively for the telehealth arm. Differences scores for A1C level and surveys were computed between baseline and three months and compared across arms using a two-sample t test or Mann-Whitney U test.

RESULTS

Patients in the telehealth arm completed a median of eight visits (IQR: 5, 8), and 53% of those in the telephone arm completed 100% of their calls. Change in HbA1c was greater for those in the telephone arm (-2.57 vs -2.07%, P = .70) but the mean baseline HbA1c was higher in the telephone group (11.1% vs 10.3%). Although the change in HbA1c was not statistically different across arms, it was clinically significant.

CONCLUSIONS

Augmenting care as usual with telehealth provided by telephone or tablet can be of benefit in improving glycemic control in NHB and H/L with type 2 diabetes. Larger studies need to explore this further.

Ethnic differences in guideline-indicated statin initiation for people with type 2 diabetes in UK primary care, 2006-2019: A cohort study

BACKGROUND

Type 2 diabetes is 2-3 times more prevalent in people of South Asian and African/African Caribbean ethnicity than people of European ethnicity living in the UK. The former 2 groups also experience excess atherosclerotic cardiovascular disease (ASCVD) complications of diabetes. We aimed to study ethnic differences in statin initiation, a cornerstone of ASCVD primary prevention, for people with type 2 diabetes.

METHODS AND FINDINGS

Observational cohort study of UK primary care records, from 1 January 2006 to 30 June 2019. Data were studied from 27,511 (88%) people of European ethnicity, 2,386 (8%) people of South Asian ethnicity, and 1,142 (4%) people of African/African Caribbean ethnicity with incident type 2 diabetes, no previous ASCVD, and statin use indicated by guidelines. Statin initiation rates were contrasted by ethnicity, and the number of ASCVD events that could be prevented by equalising prescribing rates across ethnic groups was estimated. Median time to statin initiation was 79, 109, and 84 days for people of European, South Asian, and African/African Caribbean ethnicity, respectively. People of African/African Caribbean ethnicity were a third less likely to receive guideline-indicated statins than European people (n/N [%]: 605/1,142 [53%] and 18,803/27,511 [68%], respectively; age- and gender-adjusted HR 0.67 [95% CI 0.60 to 0.76], p < 0.001). The HR attenuated marginally in a model adjusting for total cholesterol/high-density lipoprotein cholesterol ratio (0.77 [95% CI 0.69 to 0.85], p < 0.001), with no further diminution when deprivation, ASCVD risk factors, comorbidity, polypharmacy, and healthcare usage were accounted for (fully adjusted HR 0.76 [95% CI 0.68, 0.85], p < 0.001). People of South Asian ethnicity were 10% less likely to receive a statin than European people (1,489/2,386 [62%] and 18,803/27,511 [68%], respectively; fully adjusted HR 0.91 [95% CI 0.85 to 0.98], p = 0.008, adjusting for all covariates). We estimated that up to 12,600 ASCVD events could be prevented over the lifetimes of people currently affected by type 2 diabetes in the UK by equalising statin prescribing across ethnic groups. Limitations included incompleteness of recording of routinely collected data.

CONCLUSIONS

In this study we observed that people of African/African Caribbean ethnicity with type 2 diabetes were substantially less likely, and people of South Asian ethnicity marginally less likely, to receive guideline-indicated statins than people of European ethnicity, even after accounting for sociodemographics, healthcare usage, ASCVD risk factors, and comorbidity. Underuse of statins in people of African/African Caribbean or South Asian ethnicity with type 2 diabetes is a missed opportunity to prevent cardiovascular events.

A Serpin With a Finger in Many PAIs: PAI-1's Central Function in Thromboinflammation and Cardiovascular Disease

Plasminogen activator inhibitor 1 (PAI-1) is a member of the serine protease inhibitor (serpin) superfamily. PAI-1 is the principal inhibitor of the plasminogen activators, tissue plasminogen activator (tPA), and urokinase-type plasminogen activator (uPA). Turbulence in the levels of PAI-1 tilts the balance of the hemostatic system resulting in bleeding or thrombotic complications. Not surprisingly, there is strong evidence that documents the role of PAI-1 in cardiovascular disease. The more recent uncovering of the coalition between the hemostatic and inflammatory pathways has exposed a distinct role for PAI-1. The storm of proinflammatory cytokines liberated during inflammation, including IL-6 and TNF-α, directly influence PAI-1 synthesis and increase circulating levels of this serpin. Consequently, elevated levels of PAI-1 are commonplace during infection and are frequently associated with a hypofibrinolytic state and thrombotic complications. Elevated PAI-1 levels are also a feature of metabolic syndrome, which is defined by a cluster of abnormalities including obesity, type 2 diabetes, hypertension, and elevated triglyceride. Metabolic syndrome is in itself defined as a proinflammatory state associated with elevated levels of cytokines. In addition, insulin has a direct impact on PAI-1 synthesis bridging these pathways. This review describes the key physiological functions of PAI-1 and how these become perturbed during disease processes. We focus on the direct relationship between PAI-1 and inflammation and the repercussion in terms of an ensuing hypofibrinolytic state and thromboembolic complications. Collectively, these observations strengthen the utility of PAI-1 as a viable drug target for the treatment of various diseases.

Sleep insufficiency and incident diabetes mellitus among indigenous and minority populations in Greece

Objective

To investigate the potential association between sleep pathology and diabetes mellitus (DM) using self-reported questionnaires.

Material and Methods

957 adults aged between 19 and 86 years old were enrolled in this cross-sectional study. Multistage stratified cluster sampling was used and subjects were classified into three groups [short (<6h), normal (6-8h) and long (>8h) sleep duration]. Individuals were classified as diabetics if they responded positively to the questions: “Have you ever been told that you are diabetic or have high blood sugar by a health professional?” or “Are you on antidiabetic medication?”. Sleep quality, utilizing Epworth sleepiness scale, Athens insomnia scale, Pittsburgh sleep quality index and Berlin questionnaire, was also examined.

Results

DM prevalence was higher among expatriated and Muslim Greeks (23.1% and 18.7%, respectively) compared to indigenous Greek Christians (4.4%). DM prevalence was significantly associated with short sleep duration (aOR=2.82, p<0.001), excessive daytime sleepiness (aOR=2.09, p=0.019) and poor sleep quality (aOR=2.56, p<0.001), while its relation with insomnia (aOR=1.63, p=0.065) and risk for obstructive sleep apnea (aOR=1.53, p=0.080) were of marginal statistical significance.

Conclusion

This study indicates an association between sleep quantity, quality and DM and supports early pharmacological and cognitive behavioral interventions on sleep disturbances in order to reduce the burden of DM with increased focus on minority population needs.

Type 2 Diabetes as a Determinant of Parkinson's Disease Risk and Progression

Background:

Type 2 diabetes (T2DM) and Parkinson’s disease (PD) are prevalent diseases that affect an aging population. Previous systematic reviews and meta-analyses have explored the relationship between diabetes and the risk of PD, but the results have been conflicting.

Objective:

The objective was to investigate T2DM as a determinant of PD through a meta-analysis of observational and genetic summary data.

Methods:

A systematic review and meta-analysis of observational studies was undertaken by searching 6 databases. We selected the highest-quality studies investigating the association of T2DM with PD risk and progression. We then used Mendelian randomization (MR) to investigate the causal effects of genetic liability toward T2DM on PD risk and progression, using summary data derived from genome-wide association studies.

Results:

In the observational part of the study, pooled effect estimates showed that T2DM was associated with an increased risk of PD (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.07–1.36), and there was some evidence that T2DM was associated with faster progression of motor symptoms (standardized mean difference [SMD] 0.55, 95% CI 0.39–0.72) and cognitive decline (SMD −0.92, 95% CI −1.50 to −0.34). Using MR, we found supportive evidence for a causal effect of diabetes on PD risk (inverse-variance weighted method [IVW] OR 1.08, 95% CI 1.02–1.14; P = 0.010) and some evidence of an effect on motor progression (IVW OR 1.10, 95% CI 1.01–1.20; P = 0.032) but not on cognitive progression.

Conclusions:

Using meta-analyses of traditional observational studies and genetic data, we observed convincing evidence for an effect of T2DM on PD risk and new evidence to support a role in PD progression.

Common mechanisms for type 2 diabetes and psychosis: Findings from a prospective birth cohort

BACKGROUND

Psychosis and type 2 diabetes mellitus (T2DM) are commonly comorbid and may share pathophysiologic mechanisms. To investigate shared genetic variation and inflammation as potential common mechanisms, we tested: (i) associations between genetic predisposition for T2DM and psychotic experiences and psychotic disorder in young adults; (ii) the association between genetic predisposition for schizophrenia and insulin resistance (IR), a precursor of T2DM; and (iii) whether these associations are mediated by childhood inflammation.

METHODS

Psychotic experiences (PEs), psychotic disorder and IR were assessed at age 18. Polygenic risk scores (PRS) for T2DM and schizophrenia were derived based on large genome-wide association studies. Associations between PRS and psychotic/IR outcomes were assessed using regression analysis based on 3768 ALSPAC birth cohort participants with complete data. Inflammatory markers C-reactive protein (CRP) and interleukin 6 (IL-6) measured at age 9 were used in regression and mediation analyses.

RESULTS

Genetic predisposition for T2DM was associated with PEs (adjusted OR = 1.21; 95% CI, 1.01-1.45) and psychotic disorder (adjusted OR = 1.51; 95% CI, 1.04-2.03) at age 18 in a linear dose-response fashion. Genetic predisposition for schizophrenia was weakly associated with IR (adjusted OR = 1.10; 95% C·I, 0.99-1.22) at age 18. The association between genetic risk for T2DM and PEs was partly mediated by childhood CRP (p = .040).

CONCLUSIONS

Comorbidity between psychosis and T2DM may be partly underpinned by shared genes and inflammation. A summation of minor genetic variation representing lifetime risk for T2DM at conception may predispose individuals to psychosis in adulthood by influencing physiologic changes, such as low-grade inflammation, detectable as early as childhood.

Established and novel gender dimorphisms in type 2 diabetes mellitus: Insights from a multiethnic cohort

BACKGROUND AND AIMS

In type 2 diabetes mellitus (T2DM), sexual dimorphisms modulate the natural histories of hyperglycemia, anthropophysical/cardiometabolic phenotype, and susceptibility to chronic micro and macrovascular complications. The purpose of this work was to revisit known or new dimorphisms within a multiethnic cohort.

METHODS

Among 1238 T2DM patients, men (63%) were compared to women (37%), including leading ethnicities: Whites (67.4%; 542 men; 293 women); Maghrebians (9.4%; 62 men; 54 women); and Blacks (12.5%; 92 men; 63 women).

RESULTS

Age, BMI, diabetes duration, insulin sensitivity, B-cell function loss, HbA1c, and hyperglycemia index were similar in both genders. All-cause microangiopathy and cerebrovascular disease did not differ between sexes. Women had significantly more retinopathy (27% vs. 21%) and men more microalbuminuria (25% vs. 19%), all-cause macroangiopathy (40% vs. 26%), CAD (29% vs. 17%) and PAD (11% vs. 6%). Among Blacks, sexual dimorphism in terms of retinopathy was more pronounced (24% in women vs. 11%), while there was no sexual dimorphism in all-cause macroangiopathy, CAD or PAD. B-cell function loss was faster among North African men (+15%), who also had more hepatic steatosis (+27%) than women.

CONCLUSIONS

T2DM abolishes the CV protection provided by the female gender in Blacks. In White women, the loss of CV protection in diabetes is limited to cerebrovascular disease. In Black women, a markedly increased risk of retinopathy is present, despite glycemic exposure similat to men. Sexual dimorphisms do not affect glucose homeostasis and metabolic control in all ethnicities, except for lesser B-cell function loss in Maghrebian women.

A clinical risk score to identify patients with COVID-19 at high risk of critical care admission or death: An observational cohort study

BACKGROUND

The COVID-19 pandemic continues to escalate. There is urgent need to stratify patients. Understanding risk of deterioration will assist in admission and discharge decisions, and help selection for clinical studies to indicate where risk of therapy-related complications is justified.

METHODS

An observational cohort of patients acutely admitted to two London hospitals with COVID-19 and positive SARS-CoV-2 swab results was assessed. Demographic details, clinical data, comorbidities, blood parameters and chest radiograph severity scores were collected from electronic health records. Endpoints assessed were critical care admission and death. A risk score was developed to predict outcomes.

FINDINGS

Analyses included 1,157 patients. Older age, male sex, comorbidities, respiratory rate, oxygenation, radiographic severity, higher neutrophils, higher CRP and lower albumin at presentation predicted critical care admission and mortality. Non-white ethnicity predicted critical care admission but not death. Social deprivation was not predictive of outcome. A risk score was developed incorporating twelve characteristics: age>40, male, non-white ethnicity, oxygen saturations<93%, radiological severity score>3, neutrophil count>8.0 x109/L, CRP>40 mg/L, albumin<34 g/L, creatinine>100 µmol/L, diabetes mellitus, hypertension and chronic lung disease. Risk scores of 4 or higher corresponded to a 28-day cumulative incidence of critical care admission or death of 40.7% (95% CI: 37.1 to 44.4), versus 12.4% (95% CI: 8.2 to 16.7) for scores less than 4.

INTERPRETATION

Our study identified predictors of critical care admission and death in people admitted to hospital with COVID-19. These predictors were incorporated into a risk score that will inform clinical care and stratify patients for clinical trials.

Obtaining evidence base for the development of Feel4Diabetes intervention to prevent type 2 diabetes - a narrative literature review

BACKGROUND

Feel4Diabetes was a school and community based intervention aiming to promote healthy lifestyle and tackle obesity for the prevention of type 2 diabetes among families in 6 European countries. We conducted this literature review in order to guide the development of evidence-based implementation of the Feel4Diabetes intervention. We focused on type 2 diabetes prevention strategies, including all the phases from risk identification to implementation and maintenance. Special focus was given to prevention among vulnerable groups and people under 45 years.

METHODS

Scientific and grey literature published between January 2000 and January 2015 was searched for relevant studies using electronic databases. To present the literature review findings in a systematic way, we used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. A complementary literature search from February 2015 to December 2018 was also conducted.

RESULTS

The initial review included 27 studies with a follow-up ≥12 months and 9 studies with a follow-up ≥6 months and with a participant mean age < 45 years. We found out that interventions should be targeted at people at risk to improve recruiting and intervention effectiveness. Screening questionnaires (primarily Finnish Diabetes Risk Score FINDRISC) and blood glucose measurement can both be used for screening; the method does not appear to affect intervention effectiveness. Screening and recruitment is time-consuming, especially when targeting lower socioeconomic status and age under 45 years. The intervention intensity is more important for effectiveness than the mode of delivery. Moderate changes in several lifestyle habits lead to good intervention results. A minimum of 3-year follow-up seemed to be required to show a reduction in diabetes risk in high-risk individuals. In participants < 45 years, the achieved results in outcomes were less pronounced. The complementary review included 12 studies, with similar results regarding intervention targets and delivery modes, as well as clinical significance.

CONCLUSION

This narrative review highlighted several important aspects that subsequently guided the development of the Feel4Diabetes high-risk intervention. Research on diabetes prevention interventions targeted at younger adults or vulnerable population groups is still relatively scarce. Feel4Diabetes is a good example of a project aiming to fill this research gap.

TRIAL REGISTRATION

clinicaltrials.gov NCT02393872, registered 20th March 2015.

Prediabetes and diabetes prevalence and risk factors comparison between ethnic groups in the United Arab Emirates

The economic growth has paralleled the rise of diabetes and its complications in multiethnic population of United Arab Emirates (UAE). Previous studies have shown that characteristics of diabetes is variable across different ethnicities. The objective of this study was to compare diabetes prevalence and risk factors between UAE nationals and different expatriate’s ethnic groups in UAE using data from UAE National Diabetes and Lifestyle Study (UAEDIAB). The UAE nationals made one-fourth (n = 797, 25%) of total cohort and the remaining 75% belonged to immigrants. Across different ethnicities, adjusted prevalence of prediabetes ranged from 8% to 17%, while adjusted prevalence of newly diagnosed diabetes ranged from 3% to 13%. UAE nationals, Arabs non-nationals and Asians had the highest number of pre-diabetic as well as newly diagnosed diabetic patients. Adjusted prevalence of diabetes was highest in UAE nationals (male 21% and female 23%) as well as Asian non-Arabs (male 23% and female 20%), where 40% of both groups fell under the range of either prediabetes or diabetes conditions. Multivariate factors of diabetes versus non-diabetes included older age, ethnicities of Asian non-Arabs and local UAE nationals, family history of diabetes, obesity, snoring, decreased level of high density lipoprotein, elevated levels of triglycerides and blood pressure. In conclusion, diabetes prevalence and risk factors vary across the different ethnic groups in UAE, and hence interventions towards identification and prevention of diabetes should not treat all patients alike.

Ethnicity and Type 2 diabetes in the UK

Type 2 diabetes is a major UK public health priority. Among minority ethnic communities, the prevalence is alarmingly high, approximately three to five times higher than in the white British population. Particularly striking is the earlier onset of Type 2 diabetes, which occurs some 10-12 years younger, with a significant proportion of cases being diagnosed before the age of 40 years. This review focuses on the UK context and Type 2 diabetes in adult populations, exploring the available evidence regarding the complex interplay of biological, lifestyle, social, clinical and healthcare system factors that are known to drive these disparities.

Prevalence and progression of diabetic nephropathy in South Asian, white European and African Caribbean people with type 2 diabetes: A systematic review and meta-analysis

AIMS

To conduct a systematic review and meta-analysis of published observational evidence to assess the difference in the prevalence and progression of diabetic nephropathy, and the development of end-stage renal disease (ESRD) in people from three different ethnic groups with type 2 diabetes (T2DM).

MATERIALS AND METHODS

Relevant studies were identified in a literature search of MEDLINE, EMBASE and reference lists of relevant studies published up to May 2018. We decided a priori that there were no differences in the prevalence and progression of diabetic nephropathy, and the development of ESRD in the three ethnicities with T2DM. Pooled relative risks of microalbuminuria by ethnicity were estimated by fitting three random effects meta-analyses models. A narrative synthesis of the nephropathy progression in the studies was carried out. The review was registered in PROSPERO (CRD42018107350).

RESULTS

Thirty-two studies with data on 153 827 unique participants were eligible for inclusion in the review. The pooled prevalence ratio of microalbuminuria in South Asian compared with white European participants was 1.14 (95% confidence interval [CI] 0.99, 1.32; P = 0.065), while for African Caribbean vs South Asian participants the pooled prevalence ratio was 1.08 (95% CI 0.93, 1.24; P = 0.327). Results for renal decline were inconsistent, with preponderance towards a high rate of disease progression in South Asian compared with white participants. The estimated pooled incidence rate ratio (IRR) for ESRD was significantly higher in African Caribbean vs white European participants: 2.75 (95% CI 2.01, 3.48; P < 0.001).

CONCLUSION

The results of this review did not show a significant link between ethnicity (South Asian, white European and African Caribbean) and the prevalence of microalbuminuria; however, the IRR for ESRD in African Caribbean compared with white European participants was significantly higher. Further research is needed to explore the potential non-albuminuric pathways of progression to ESRD.

Non-communicable diseases in migrants: an expert review

BACKGROUND

Non-communicable diseases (NCDs) remain a major challenge in the 21st century. High-income countries (HICs) populations are ethnically and culturally diverse due to international migration. Evidence suggests that NCDs rates differ between migrants and the host populations in HICs. This paper presents a review of NCDs burden among migrant groups in HICs in Europe, North America and Australia with a major focus on cardiovascular diseases (CVDs), cancer and diabetes.

METHODS

We performed a narrative review consisting of scholarly papers published between 1960 until 2018.

RESULTS

CVD risk differs by country of origin, country of destination and duration of residence. For example, stroke is more common in sub-Sahara African and South-Asian migrants, but lower in North African and Chinese migrants. Chinese migrants, however, have a higher risk of haemorrhagic stroke despite the lower rate of overall stroke. Coronary heart disease (CHD) is more common in South-Asian migrants, but less common in sub-Saharan and north African migrants although the lower risk of CHD in these population is waning. Diabetes risk is higher in all migrants and migrants seem to develop diabetes at an earlier age than the host populations. Migrants in general have lower rates of overall cancer morbidity and mortality than the host populations in Europe. However, migrants have a higher infectious disease-related cancers than the host populations in Europe. In North America, the picture is more complex. Data from cross-national comparisons indicate that migration-related lifestyle changes associated with the lifestyle of the host population in the country of settlement may influence NCDs risk among migrants in a very significant way.

CONCLUSION

With exception of diabetes, which is consistently higher in all migrant groups than in the host populations, the burden of NCDs among migrants seems to depend on the migrant group, country of settlement and NCD type. This suggests that more work is needed to disentangle the key migration-related lifestyle changes and contextual factors that may be driving the differential risk of NCDs among migrants in order to assist prevention and clinical management of NCDs in these populations.

A cross-sectional survey of general practice health workers' perceptions of their provision of culturally competent services to ethnic minority people with diabetes

AIMS

To explore General Practice teams cultural-competence, in particular, ethnicity, linguistic skillset and cultural awareness. The practice teams' access to diabetes-training, and overall perception of cultural-competence were also assessed.

METHODS

A cross-sectional single-city-survey with one in three people with diabetes from an ethnic minority group, using 35 semi-structured questions was completed. Self-reported data analysed using descriptive statistics, interpreted with reference to the Culturally-Competent-Assessment-Tool.

RESULTS

Thirty-four (52%) of all 66 practices in Coventry responded between November 2011 and January 2012.

KEY FINDINGS

(1) One in five practice staff was from a minority group in contrast with one in ten of Coventry's population, (2) 164 practice staff (32%) spoke a second language relevant to the practice's minority population, (3) 56% of practices were highly culturally-competent at providing diabetes services for minority populations, (4) 94% of practices reported the ethnicity of their populations, and (5) the most frequently stated barriers to culturally-competent service delivery were language and knowledge of nutritional habits.

CONCLUSIONS

Culturally-competent diabetes care is widespread across the city. Language barriers are being addressed, cultural knowledge of diabetes-related-nutrition requires further improvement. Further studies should investigate if structured cultural-competence training for diabetes service providers produces positive effects in diabetes-related outcome-measures in minority populations.

Diabetes prevalence in rural Indigenous Guatemala: A geographic-randomized cross-sectional analysis of risk

BACKGROUND

Developing countries and Indigenous populations are disproportionately affected by global trends in diabetes (T2DM), but inconsistent data are available to corroborate this pattern in Guatemala and indigenous communities in Central America. Historic estimates of T2DM, using a variety of sampling techniques and diagnostic methods, in Guatemala include a T2DM prevalence of: 4·2% (1970) and 8·4% (2003). Objectives of this geographically randomized, cross-sectional analysis of risk include: (1) use HbA1c to determine prevalence of T2DM and prediabetes in rural Indigenous community of Atitlán (2) identify risk factors for T2DM including age, BMI and gender.

METHODS

A spatially random sampling method was used to identify 400 subjects. Prevalence was compared using the confidence interval method, and logistic regression and linear regression were used to assess association between diabetes and risk factors.

FINDINGS

The overall prevalence of T2DM using HbA1c was 13·81% and prediabetes was also 13·81% in Atitlán, representing a tripling in diabetes from historic estimates and a large population with pre-diabetes. The probability of diabetes increased dramatically with increasing age, however no significant overall relationship existed with gender or BMI.

CONCLUSIONS

Diabetes is a larger epidemic than previously expected and appears to be related to ageing rather than BMI. Our proposed explanations for these findings include: possible Indigenous unique genetic susceptibility to T2DM, shortcomings in BMI as a metric for adiposity in assessing risk, changes in lifestyle and diet, and an overall aging population. The conclusion of this study suggest that (1) T2DM in rural regions of Guatemala may be of epidemic proportion. With pre-diabetes, more than 25% of the population will be diabetic in the very near future; (2) Age is a significant risk factor in the Indigenous population but BMI is not. This suggests that in some populations diabetes may be a disease of ageing.

Differences in prevalence of diabetes among immigrants to Canada from South Asian countries

AIMS

The prevalence of diabetes is high in South Asians migrants. However, most previous research has studied South Asians as a collective whole. The aim of this study was to examine diabetes prevalence among immigrants from five South Asian countries living in Ontario, Canada.

METHODS

Population-based health care and immigration databases were used to compare crude and adjusted diabetes prevalence on 1 January 2012 between immigrants to Ontario from different South Asians countries and the non-immigrant population. The prevalence of diabetes was also stratified by various sociodemographic factors.

RESULTS

There were 431 765 first-generation South Asian immigrants; 68 440 (crude prevalence of 15.9%) of whom had a diagnosis of diabetes. After standardization for age, sex and income, diabetes prevalence was highest among South Asians from Sri Lanka (26.8%) followed by Bangladesh (22.2%), Pakistan (19.6%), India (18.3%) and Nepal (16.5%) in comparison with the non-immigrant population (11.6%). Increased prevalence was evident among men compared with women in each country of South Asia. Sociodemographic indicators including income, education, English proficiency and refugee status were associated with increased prevalence of diabetes in specific populations from South Asia.

CONCLUSION

Striking differences in the prevalence of diabetes are evident among immigrants from different countries of South Asia. Awareness of the heterogeneity will help in recognizing priorities for the delivery of primary care for specific South Asian migrant populations with a range of settlement needs that also encompass social determinants of health.

Prevalence and incidence of complications at diagnosis of T2DM and during follow-up by BMI and ethnicity: a matched case-control analysis

Aims

To estimate the risk of developing long-term major cardiovascular and renal complications in relation to levels of body mass index (BMI) in a population of White European (WE), African-Caribbean (AC), and South Asian (SA) patients with type 2 diabetes mellitus (T2DM).

Materials and methods

Patients with new diagnosis of T2DM, aged ≥ 18 years from January 2000 (n = 69,436) and their age-sex-ethnicity matched non-diabetic controls (n = 272,190) were identified from UK primary care database. Incidence rates ratios (IRRs) for non-fatal major cardiovascular events (MACE) and chronic kidney disease (CKD) in patients with T2DM compared to controls were estimated using multivariate Mantel-Cox model.

Results

Among normal weight patients with T2DM, WEs had significantly higher prevalence of cardiovascular multi-morbidity (95% CI 9.5, 11.3), compared to SAs (95% CI 4.8, 9.5). AC and SA overweight and obese patients had similar prevalence, while obese WEs had significantly higher prevalence. During a median 7 years of follow-up, risk of MACE was significantly higher for overweight (95% CI of IRR 1.50, 2.46) and obese (95% CI of IRR 1.49, 2.43) SAs compared to their WE counterparts. However, similar risk levels were observed for normal weight WEs and SAs, respectively. Risk of CKD was higher and uniform for BMI ≥ 25 kg/m² amongst WEs and ACs, whereas only overweight patients had significantly higher risk of CKD amongst SA [IRR 2.08 (95% CI 1.49, 2.93)].

Conclusion

Risk of MACE/CKD varies over levels of BMI within each ethnic group, with overweight SAs having a disproportionate risk of CKD.

Electronic supplementary material

The online version of this article (10.1186/s12933-018-0712-1) contains supplementary material, which is available to authorized users.

The Effect of Neighborhood Disadvantage on Diabetes Prevalence

Patient socioeconomic data is not usually included in medical records nor easily accessible to clinicians, yet socioeconomic disadvantage can be an important guide to disease management. This study evaluated the neighborhood-level Area Deprivation Index (ADI), a measure of neighborhood socioeconomic disadvantage, as a factor in diabetes mellitus prevalence. Electronic health records at an academic hospital system identified 4,770 Medicare beneficiaries. Logistic regression of diabetes diagnosis (ICD9=250.x) against ADI quintile, age, gender, and race/ethnicity found all these patient characteristics to be significantly associated. Diabetes prevalence was lowest in the least disadvantaged quintile of neighborhoods after adjusting for age, gender, and race/ethnicity. The positive non-linear association of diabetes prevalence with ADI demonstrates the power of this index to practically quantify socioeconomic disadvantage. The ADI may be suitable for clinical decision support, and for informing the policy changes which are needed to reduce socioeconomic disparities in diabetes prevalence and other health outcomes.

A Class Comparison of Medication Persistence in People with Type 2 Diabetes: A Retrospective Observational Study

INTRODUCTION

Longer medication persistence in type 2 diabetes (T2D) is associated with improved glycaemic control. It is not clear which oral therapies have the best persistence. The objective of this study was to compare medication persistence across different oral therapies in people with T2D.

METHODS

We performed a retrospective cohort analysis using a primary-care-based population, the Royal College of General Practitioners Research and Surveillance Centre cohort. We identified new prescriptions for oral diabetes medication in people with type 2 diabetes between January 1, 2004 and July 31, 2015. We compared median persistence across each class. We also compared non-persistence (defined as a prescription gap of ≥ 90 days) between classes, adjusting for confounders, using Cox regression. Confounders included: age, gender, ethnicity, socioeconomic status, alcohol use, smoking status, glycaemic control, diabetes duration, diabetes complications, comorbidities, and number of previous and concurrent diabetes medications.

RESULTS

We identified 60,327 adults with T2D. The majority 42,810 (70.9%) of those had one or more oral medications prescribed; we measured persistence in those patients (who were prescribed 55,728 oral medications in total). Metformin had the longest median persistence (3.04 years; 95% CI 2.94-3.12). The adjusted hazard ratios for non-persistence compared with metformin were: sulfonylureas HR 1.20 (1.16-1.24), DPP-4 inhibitors HR 1.43 (1.38-1.49), thiazolidinediones HR 1.71 (95% CI 1.64-1.77), SGLT2 inhibitors HR 1.04 (0.93-1.17), meglitinides HR 2.25 (1.97-2.58), and alpha-glucosidase inhibitors HR 2.45 (1.98-3.02). The analysis of SGLT2 inhibitors was limited by the short duration of follow-up for this new class. Other factors associated with reduced medication persistence were female gender, younger age, and non-white ethnicity.

CONCLUSIONS

Persistence is strongly influenced by medication class and should be considered when initiating treatments.

Epidemiology of hypertension in Fulani indigenous populations-age, gender and drivers

BACKGROUND

Hypertension is a public health problem and the main contributor to cardiovascular mortality and morbidity. Little is known about hypertension among the minority, diverse and socially disadvantaged 23-24 million Fulani/Peul populations dispersed in West, Central and East Africa, undergoing a transition from traditional to transitional and modern lifestyle. This study describes age and gender variations in blood pressure and drivers of hypertension among rural Fulani population of Cameroon.

METHODS

We analysed population-based cross-sectional data collected in 2013 by standard methods from 1337 Fulani/Peul aged ≥ 20 years. Hypertension was defined as systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg or current use of anti-hypertensive medication. We elucidated the occurrence and drivers of hypertension by chi-square test, Student's t test and univariate and multivariable logistic regression models.

RESULTS

The prevalence of hypertension was 31.1% (men 36.5% and women 28.7%). Systolic and diastolic blood pressure increased with age. Older women suffered more from grades 1, 2 and 3 hypertension than older men. Old age, divorced/separated, never attended school, current/former smoker, family history (FH) of hypertension, diabetic, underweight and substantially increased risk from waist circumference were independently associated with hypertension. Insomnia and had 8-12 children were the only drivers of hypertension among men.

CONCLUSION

Prevalence of hypertension was high. Awareness and control were low. Hypertension prevalence increased with age and was more prevalent among men than women. Older women experienced severe hypertension more than older men. Culturally embedded interventions are warranted to curb the high burden of hypertension among the Fulani.

Early onset of type 2 diabetes among visible minority and immigrant populations in Canada

OBJECTIVES

Type 2 diabetes is a chronic condition that affects nearly over three million Canadians, including immigrants. The timing of the first onset of diabetes has been linked to several other severe diseases. Yet, there is a dearth of empirical studies that examine the timing of the first onset of diabetes among Canadians, in general, and among immigrants and ethnic minority populations within Canada, in particular.

DESIGN

Applying event history techniques to the 2013 Canadian Community and Health Survey, we address this research void by examining factors that contribute to the first onset of diabetes among immigrant and visible minority populations in Canada (N = 8905). Given the gendered patterns in the epidemiology of diseases and the differences in risk factors for men and women, gender-specific models were estimated.

RESULTS

Results showed that South Asian, Black and Filipino women developed diabetes earlier, compared to women from the UK. Similarly, South Asian, Chinese, Filipino, Black, South East Asian and Arab men developed diabetes earlier than men from the UK. A significant and important finding of this analysis was that the risks of developing diabetes vanished completely for Black and Filipino women, after accounting for lifestyle factors. For South Asian women, however, there was significant attenuation in their risks after accounting for lifestyle factors. The findings were strikingly different for immigrant men. Specifically, their risks of developing diabetes increased after accounting for lifestyle factors.

CONCLUSIONS

These results suggest the development of gender-specific and lifestyle interventions, targeted at specific immigrant groups with increased risks of developing diabetes earlier in the life course.

Methods needed to measure predictive accuracy: A study of diabetic patients

Diabetes is one of the leading causes of morbidity and mortality and it can result in several complications such as kidney failure, heart failure, stroke, and blindness making it a major medical and public health concern in the United States. Statistical methods are important to detect risk factors and identify the best sampling plan to determine predictive bounds for diabetic patients' data. The main objective of this paper is to identify the best fit bootstrapping sampling method and to draw the predictive bound considering diabetes patient data. A random sample was used from the National Health and Nutritional Examination Survey (NHANES) for this study. We found that there were significant relationships between age, marital status, and race/ethnicity with diabetes status (p<0.001) and no relationship was observed between gender and diabetes status. We ran the logistic regression to identify the risk factors from the data. We identified that the significant risk factors are age (p<0.001), total protein (p<0.001), fast food (p<0.0339), and direct HDL (p<0.001). This study provides evidence that the parametric bootstrapping method is the best fit method compared with other methods to estimate the predictive error bounds. These findings will be of great significance for identifying the best sampling methods, which can increase the statistical accuracy of laboratory clinical research of diabetes. This will also allow for the determination of precise risk factors that will best represent the data by detecting mild and extreme outliers from disease observations. Therefore, these results will be useful for researchers and clinicians to select the best sampling methods to study diabetes and other diseases in order to maximize the accuracy of their results. This article is part of a Special Issue entitled: Oxidative Stress and Mitochondrial Quality in Diabetes/Obesity and Critical Illness Spectrum of Diseases - edited by P. Hemachandra Reddy.

Life Expectancy and Cause-Specific Mortality in Type 2 Diabetes: A Population-Based Cohort Study Quantifying Relationships in Ethnic Subgroups

OBJECTIVES

This study 1) investigated life expectancy and cause-specific mortality rates associated with type 2 diabetes and 2) quantified these relationships in ethnic subgroups.

RESEARCH DESIGN AND METHODS

This was a cohort study using Clinical Practice Research Datalink data from 383 general practices in England with linked hospitalization and mortality records. A total of 187,968 patients with incident type 2 diabetes from 1998 to 2015 were matched to 908,016 control subjects. Abridged life tables estimated years of life lost, and a competing risk survival model quantified cause-specific hazard ratios (HRs).

RESULTS

A total of 40,286 deaths occurred in patients with type 2 diabetes. At age 40, white men with diabetes lost 5 years of life and white women lost 6 years compared with those without diabetes. A loss of between 1 and 2 years was observed for South Asians and blacks with diabetes. At age older than 65 years, South Asians with diabetes had up to 1.1 years' longer life expectancy than South Asians without diabetes. Compared with whites with diabetes, South Asians with diabetes had lower adjusted risks for mortality from cardiovascular (HR 0.82; 95% CI 0.75, 0.89), cancer (HR 0.43; 95% CI 0.36, 0.51), and respiratory diseases (HR 0.60; 95% CI 0.48, 0.76). A similar pattern was observed in blacks with diabetes compared with whites with diabetes.

CONCLUSIONS

Type 2 diabetes was associated with more years of life lost among whites than among South Asians or blacks, with older South Asians experiencing longer life expectancy compared with South Asians without diabetes. The findings support optimized cardiovascular disease risk factor management, especially in whites with type 2 diabetes.

Culturally Targeted Strategies for Diabetes Prevention in Minority Population

Purpose The purpose of this study is to (a) assess the effectiveness of culturally tailored diabetes prevention interventions in minority populations and (b) develop a novel framework to characterize 4 key domains of culturally tailored interventions. Prevention strategies specifically tailored to the culture of ethnic minority patients may help reduce the incidence of diabetes. Methods We searched PubMed, EMBASE, and CINAHL for English-language, randomized controlled trials (RCTs) or quasi-experimental (QE) trials testing culturally tailored interventions to prevent diabetes in minority populations. Two reviewers independently extracted data and assessed risk of bias. Inductive thematic analysis was used to develop a framework with 4 domains (FiLLM: Facilitating [ie, delivering] Interventions Through Language, Location, and Message). The framework was used to assess the overall effectiveness of culturally tailored interventions. Results Thirty-four trials met eligibility criteria. Twelve studies were RCTs, and 22 were QE trials. Twenty-five out of 34 studies (74%) that used cultural tailoring demonstrated significantly improved A1C, fasting glucose, and/or weight loss. Of the 25 successful interventions, 21 (84%) incorporated at least 3 culturally targeted domains. Seven studies used all 4 domains and were all successful. The least utilized domain was delivery (4/34) of the intervention's key educational message. Conclusions Culturally tailoring interventions across the 4 domains of facilitators, language, location, and messaging can be effective in improving risk factors for progression to diabetes among ethnic minority groups. Future studies should evaluate how specific tailoring approaches work compared to usual care as well as comparative effectiveness of each tailoring domain.

Migrant adults with diabetes in France: Influence of family migration

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There is a high prevalence of poorly controlled diabetes in migrants.

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Family gathering is associated with a better control of diabetes.

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Exploration of migration’ story is important in the health care process.

Aim

To explore the influence of migration and this parameters on the control of diabetes.

Methods

A cohort of migrant patients with type 2 diabetes was recruited in a center affiliated to the French national insurance system situated in a department with important migratory phenomenon. Patients fulfilled a questionnaire about diabetes, their migration history, and the EPICES score (deprivation score). We have explored by univariate and multivariate analysis if any of the characteristics of migration could be related to the control of diabetes. This cohort was compared to a non-migrant control group of age and sex-matched patients.

Results

We included 72 patients, 36 women and 36 men from 20 different countries. The mean age was 57.7 ± 9.6 years. A migration for family reunification was associated with better diabetes equilibrium (Risk of having an HbA1c ⩾8% (63.9 mmol/mol): OR 0.07 (95% IC [0.005–0.86], p = 0.04). The migrant patients who wished to share their time between France and country of origin during their retirement had a better glycaemic control than the migrant patients who would like to go alone into their country (OR 0.08 [0.01–0.78], p = 0.03). Compared to the non migrant group, the EPICES score was higher in the migrant group (52.8 vs. 28.3, p < 0.05), HbA1c was also higher in the migrant group (8.4 vs. 6.7% (68 vs. 50 mmol/mol)).

Conclusions

We may fear that migrants share an increased risk of uncontrolled diabetes. Individual migration could be a risk factor of uncontrolled diabetes. Knowing the migration history of migrant patients is fundamental to understand some barriers of care.

Real-world evidence studies into treatment adherence, thresholds for intervention and disparities in treatment in people with type 2 diabetes in the UK

PURPOSE

The University of Surrey-Lilly Real World Evidence (RWE) diabetes cohort has been established to provide insights into the management of type 2 diabetes mellitus (T2DM). There are 3 areas of study due to be conducted to provide insights into T2DM management: exploration of medication adherence, thresholds for changing diabetes therapies, and ethnicity-related or socioeconomic-related disparities in management. This paper describes the identification of a cohort of people with T2DM which will be used for these analyses, through a case finding algorithm, and describes the characteristics of the identified cohort.

PARTICIPANTS

A cohort of people with T2DM was identified from the Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) data set. This data set comprises electronic patient records collected from a nationally distributed sample of 130 primary care practices across England with scope to increase the number of practices to 200.

FINDINGS TO DATE

A cohort (N=58 717) of adults with T2DM was identified from the RCGP RSC population (N=1 260 761), a crude prevalence of diabetes of 5.8% in the adult population. High data quality within the practice network and an ontological approach to classification resulted in a high level of data completeness in the T2DM cohort; ethnicity identification (82.1%), smoking status (99.3%), alcohol use (93.3%), glycated haemoglobin (HbA1c; 97.9%), body mass index (98.0%), blood pressure (99.4%), cholesterol (87.4%) and renal function (97.8%). Data completeness compares favourably to other, similarly large, observational cohorts. The cohort comprises a distribution of ages, socioeconomic and ethnic backgrounds, diabetes complications, and comorbidities, enabling the planned analyses.

FUTURE PLANS

Regular data uploads from the RCGP RSC practice network will enable this cohort to be followed prospectively. We will investigate medication adherence, explore thresholds and triggers for changing diabetes therapies, and investigate any ethnicity-related or socioeconomic-related disparities in diabetes management.

Distribution and patterning of non-communicable disease risk factors in indigenous Mbororo and non-autochthonous populations in Cameroon: cross sectional study

BACKGROUND

Data on Non-Communicable Diseases (NCDs) among indigenous populations are needed for interventions to improve health care. We conducted a survey in 2013 among rural indigenous Mbororo, Fulbe and other ethnic groups to determine the distribution of risk factors of NCDs in Cameroon.

METHODS

We selected seven targets of NCD risk factors: tobacco use, alcohol use, diet (salt/sugar intake, vegetable/fruit consumption), raised blood pressure, raised blood glucose, physical inactivity and weight measures. The WHO STEPwise approach was used to collect data from 1921 consenting participants aged ≥20 years. Prevalence of NCD risk factors was summarised by descriptive statistics.

RESULTS

Underweight was widespread, Mbororo (50.8%) and Fulbe (37.2%). Increase in prevalence of six risk factors was observed among the Fulbe when compared to Mbororo. Participants aged 20-39 years had low levels of physical activity, poor diet and higher levels of alcohol consumption (except Mbororo) and those aged ≥40 years had higher prevalence of diabetes, hypertension, current smoking and overweight/obesity. Men and women differed in current smoking, occasional/daily alcohol consumption, pre-hypertension and hypertension, continuous walking for at least ten minutes, and weight measures for Fulbe and Mbororo, p < 0.05.

CONCLUSION

Distribution of NCD risk factors was high among settled Fulani (Fulbe) when compared to indigenous nomadic Fulani (Mbororo). Change from nomadic to settled life might be accompanied by higher prevalence of NCDs. This data should be used to develop intervention programmes to curb the rising burden of NCDs in rural indigenous and non-indigenous populations.

Hypertension awareness, treatment, and control among diabetic and nondiabetic individuals in a multiethnic population in the Netherlands: the HELIUS study

OBJECTIVES

There is a paucity of data on hypertension awareness, treatment and control among diabetic adults from different ethnic backgrounds. We assessed ethnic differences in prevalence, awareness, treatment, and control of hypertension among diabetic adults and how they are compared with individuals without diabetes.

METHODS

Baseline data from the Healthy Life in an Urban Setting study were used including 12 ,633 adults aged 18-70 years from six ethnic backgrounds in Amsterdam, the Netherlands. Age-sex-adjusted prevalence ratios were used to explore ethnic differences.

RESULTS

Among diabetic individuals, African-Surinamese (80.2%; 1.26, 95% confidence interval 1.06-1.51) and Ghanaians (81.7%; 1.40, 1.17-1.68) were more likely than Dutch (69.6%) to have hypertension. There were no significant ethnic differences in the rates of awareness and treatment, but blood pressure (BP) control rates among treated hypertensives were significantly lower in Ghanaians (41.7%; 0.66, 0.45-0.96) and African-Surinamese (28.7%; 0.53, 0.34-0.84) than Dutch (54.1%). Among nondiabetic adults, except Moroccans, all the ethnic minorities had higher prevalence rates of hypertension, awareness (except South-Asian Surinamese and Turks) and treatment than Dutch people. By contrast, BP control rates among treated hypertensives were lower in all ethnic minorities, with the differences being significant for African-Surinamese (42.5%; 0.68, 0.57-0.80), South-Asian Surinamese (41.8%; 0.68, 0.57-0.82), and Ghanaians (35.2%; 0.54, 0.45-0.65).

CONCLUSION

Hypertension awareness and treatment rates are similar among ethnic groups in both diabetics and nondiabetics. Adequate BP control remains low among ethnic minorities, particularly among diabetic African origin people. Major effort is needed to improve BP control among diabetic people given the cardiovascular complications associated with uncontrolled BP in this group.